Non-Alcoholic Fatty Liver Disease / Metabolic-Associated Steatotic Liver Disease Documentation Guide
Hepatic steatosis associated with metabolic risk factors in the absence of significant alcohol use.
ICD-10 Codes: K76.0, K75.81
Common Symptoms
- Often asymptomatic
- Fatigue
- Right upper quadrant discomfort
- Hepatomegaly
Key Documentation Elements
- Steatosis vs steatohepatitis distinction
- Fibrosis assessment (FIB-4 score, elastography, or biopsy)
- Metabolic risk factors (obesity, diabetes, dyslipidemia)
- Alcohol use screening results
- Liver enzymes and trends
Documentation Challenges
- Distinguishing simple steatosis from steatohepatitis
- Documenting fibrosis staging (FIB-4, elastography)
- Recording metabolic comorbidities contributing to disease
- Capturing alcohol use assessment to support diagnosis
Billing Considerations
- K76.0 for fatty liver vs K75.81 for NASH
- Documentation of metabolic comorbidities for complete coding
- Fibrosis stage documentation for severity capture
Frequently Asked Questions
What is the difference between NAFLD and MASLD?
MASLD is the updated terminology for NAFLD, emphasizing metabolic drivers. K76.0 covers fatty liver and K75.81 covers NASH/steatohepatitis. Scribeable applies the correct code based on documented findings.
How does Scribeable help with NAFLD/MASLD documentation?
Scribeable captures fibrosis scores, liver enzyme trends, metabolic comorbidities, and alcohol screening from your encounter to properly classify and code the disease stage.